CLM-2026-010535
Riverside GI Associates, Gastroenterology. Service 2026-09-13 at outpatient hospital (POS 22). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Gabriel McDonald
- Member ID
- UHC-21533-16
- Date of birth
- 1947-11-21
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-402956
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2022-10-01 to present
- Deductible
- $420.18 of $500.0084%
- Out-of-pocket maximum
- $137.76 of $1,500.009%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7858029219
- Network
- In network
- Rendering NPI
- 4204401432
- Location
- San Diego, CA · TIN 69-3440792
- Authorisation / referral
- PA2026619585 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,482.00 | $1,365.10 | $336.88 | $1,028.22 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 25 | 1 | 1 | $2,567.00 | $1,411.85 | $282.37 | $1,129.48 | Paid |
| Totals | $5,049.00 | $2,776.95 | $619.25 | $2,157.70 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-459184
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012826 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-13: NULL (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026619585 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Riverside GI Associates (7858029219). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside GI Associates2026-09-13 13:37
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Prior auth letterPA2026619585_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-13 to 2026-12-12.
- Itemized billitemized_PA-459184.pdf9 pages
Itemised statement totalling $5049.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027929 | 2026-08-10 | Mesa Behavioral Health | $2,694.00 | Needs review |
| CLM-2026-019346 | 2026-06-02 | Sunrise Counseling Center | $482.00 | Approved |
| CLM-2026-007679 | 2026-03-24 | Heritage Physical Therapy | $563.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.